Among the main bones of contention between me and conservative health reformers is that I simply don't believe a majority -- or even hefty fraction -- of patients will ever have information good enough to exert serious control over their health care decisions. Comparing TVs is easy enough, and if you make a mistake, the worst that happens is you're left with a bad TV. Deciding what heart surgeries you need -- particularly going against a doctor's judgment on the subject -- is much dicier.
But I was thinking about the TV comparison at breakfast today, and something else occurred to me. Even in consumer goods, where the information is pretty good, where we can rent the game or listen to the stereo in Best Buy, we recognize that consumer information is still pretty imperfect. For that reason, we allow people to return goods they've already bought, recognizing that amassing more information as to the product's quality or versatility can, and should, overwhelm the previous, less-informed, judgment. Quite obviously, you can't do that with an angioplasty or a lumbar surgery. So not only do you have way less information to start with, but you don't have the ability to act on post-purchase information.
Update: I should probably make my conclusion here a little less implicit. There are basically a limited number of places where micro-level treatment decisions can be made. Insurance companies, but no one wants that. The government, but no one wants that. Patients, and I'm arguing against centering the system on them. And Doctors.
Doctors tend to be my choice. The problem is, their incentives are, at the moment, all mucked up. As Jerry Avorn writes in this month's American Prospect, "what is distinctive about our system is that it provides economic incentives that encourage doing the most expensive thing all of the time to everyone who can pay for it or have it paid for." You can cut that down by making sure fewer people can pay for it, which is the Right's solution, or you can change the incentives governing the professionals who recommend the treatment, which is closer to my solution. There are a variety of policy changes that would help with this, including putting more doctors on salary rather than on fee-for-service structures, financially incentivizing the use of cost-effective treatments, putting much more money into the gathering of evidence on cost-effectiveness, etc. For more on this, Shannon Brownlee's new book, Overtreated, is supposed to be excellent. (I haven't read it yet, but will soon.)
